I wish I could say that every patient encounter worked out well, that all my patients went home happy and satisfied. It would be nice, but unfortunately that is not true at all. There are many patients who present with unrealistic expectations or an agenda which is non-therapeutic and I am relatively straightforward and unapologetic about correcting patient's misconceptions about the care that is or is not appropriate in the ED. Unsurprisingly, this often, though not always, involves narcotic medications.
Which is not to say that I am a jerk. I try to be compassionate, and I try to find alternative solutions, and I have been told that I can turn away a drug-seeker more nicely than any other doctor in the department. But when it is time to say "no," I say "no," firmly and without evasions or excuses.
People don't like to hear that. All the more so in this "the consumer is king" environment of customer-service culture we foster in the medical industry these days. So, when I do say no, as nice as I try to be, some people get upset. Sometimes they escalate. They hurl insults, spit, throw themselves on the floor and throw a fit, or feign unconsciousness. I have been threatened with complaints to administration, with lawsuits, with actions against my license, and even with physical harm. I pride myself in being determinedly polite and non-responsive to behaviors like these, since, if I engage, it only further escalates the situation, and the threats are usually empty (though I am rather security-conscious both in and out of the hospital).
I thought I had heard it all, but I got a new threat recently. The context was one in which I felt a little bad about having to say no. The patient was a grandmotherly sort of lady in her middle years. She presented a sad and pathetic figure as she told me her tale of ongoing diffuse body pain which was poorly controlled even on high doses of methadone. Alas, she was out of her meds and wanted a refill (actually, her initial request was to be admitted to the hospital). She was unable to explain how she had come to be out of her pain medications. A quick record biopsy showed that she had many, many previous ER visits for pain medicine refills, and had been on a pain contract with her doctor, who had terminated it because of her repeated violations of their agreement.
In light of this, I felt it would not have been appropriate to provide further narcotic medicines through the ER. She had been out of her meds long enough that she was not in symptomatic withdrawal. She had already been referred to a pain management clinic for future care, so there was not much more for me to do.
She escalated; I explained my thought process. She yelled, she wept, and she begged. I held firm, and she was discharged. On her way out she stopped by the charting station and said, with a vicious spite in her voice, "I hate you. You are a terrible, terrible person, and I hope you suffer, and I hope your children suffer. In fact, I am going to make sure of it. I am going to go home and make a voodoo doll of you and all of your children and I am going to stick pins in all of them!"
What does one say to that? Suddenly I didn't feel so bad about saying no any more. Bemused, I encouraged her to "have a nice day" as she stormed off.
This job is never dull.
Originally Posted 6 November 2007